Radiologic-Pathologic Correlations of the Vertebral Column Component of Ankylosing Spondylitis. Elective Student P. H.

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1 Radiologic-Pathologic Correlations of the Vertebral Column Component of Ankylosing Spondylitis Elective Student P. H.

2 Case 63 year old man Chief complaint Tingling sensation of left leg Gait disturbance Instability while descending stairs History of Presenting Illness Symptoms began 2 years ago Presented to local doctor whom then referred on to Jikei orthopedic outpatient

3 Examination Sensory disturbance of posterolateral aspect of the left leg Left gastrocnemius muscle atrophied Left ankle reflex absent Heel gait normal Toe gait and hopping not possible

4 Investigations Ankle brachial index (ABI) & Cardio-ankle vascular index (CAVI) both normal Plain film studies of the lumbar spine taken

6 Diagnosis and Management Ankylosing Spondylitis Patient was subsequently lost to follow up

7 Definition of Ankylosing Spondylitis Chronic inflammatory disorder principally involving the axial skeleton Cartilaginous joints Entheses: ligamentous, tendinous, capsular, & fascial insertions into bone Synovial joints Broad interindividual disease variance Severity Temporal Progression Appendicular skeletal and extraskeletal manifestations

8 Prevalence 0-1.4% Epidemiology, Etiology Depending on ethnic group, HLA B27 status, diagnostic criteria Male:female ratio 2-3:1 Clearly polygenic:hla B27 (20-50% of risk) HLA B27(+) status: caucasian 8% Japanese<1% HLA B27(+) monozygotic twin studies: 63% concordance Autoimmune or autoinflammatory

Intertransverse ligaments Supraspinous ligament Facet Joint Interspinous

9 Articulations of the Vertebral Arches Synovial Apophyseal/facet joints Costovertebral joints Syndesmosis Ligamenta flava Interspinous ligaments Intertransverse ligaments Supraspinous ligament Facet Joint Interspinous Ligament Supraspinous Ligament Ligamentum Flavum ALL Intertransverse Ligament PLL

10 Articulations of the Vertebral Bodies AF NP Cartilaginous endplate Calcified endplate ALL PLL

11 Articulations of the Vertebral Bodies AF NP Cartilaginous endplate Calcified endplate Sharpey`s Fibers (Entheses) ALL PLL

12 Early Radiographic Features Romanus lesions erosive lesions of the superoanterior and inferoanterior aspects of the vertebral bodies Shiny corner reactive sclerosis/eburnation following inflammatory activity Squaring of anterior vertebra

13 Syndesmophytosis Bamboo Spine Progressive syndesmophyte formation

14 Late Radiographic Features Dagger sign Calcification of the interspinous and supraspinous ligaments

15 Late Radiographic Features Trolley track sign Apophyseal joint ankylosis Capsular ossification Intraarticular ankylosis

16 Inflammation and Ankylosis Dissociated mechanisms? Syndesmophytes are more likely to develop at sites of prior inflammation

17 Inflammation and Ankylosis Dissociated mechanisms? Syndesmophytes are more likely to develop at sites of prior inflammation But most syndesmophytes appear without any preceding inflammation

18 Inflammation and Ankylosis Dissociated mechanisms? Syndesmophytes are more likely to develop at sites of prior inflammation But most syndesmophytes appear without any preceding inflammation Early inflammation may merely instigate the initial events of bony formation which subsequently continues largely independent of inflammatory activity

19 Summary A case of Ankylosing spondylitis was presented The importance of the Sharpey fibers in the pathogenesis of ankylosing spondylitis was discussed

20 Thank You Biography written by David Tucker Thought to be the 1st written account of Ankylosing Spondylitis in the US (1858)

21 References Baraliakos, X., Listing, J., et al. Radiographic progression in patients with ankylosing spondylitis after 4yrs of treatment with the anti-tnf-a antibody infliximab. Rheumatology : Gonzalez-Roces, M.V., et al. HLA B27 polymorphism and worldwide susceptibility to ankylosing spondylitis. Tissue Antigens : Pham, T. Pathophysiology of ankylosing spondylitis: What`s new? Joint Bone Spine : Resnick, D., Draud LA, Fix CF. Diagnosis of Bone and Joint Disorders: Volume 1 & 2. 4 th ed. Philadelphia, PA: Saunders; Rohen, J.W., Yokochi, C., Lutjer-Drecoll, E. Color Atlas of Anatomy: A Photographic Study of the Human Body. 4 th ed. Baltimore, MD: FK Schattauer; Van der Hejide, D., Landewe, R., et al. Radiographic progression of ankylosing spondylitis after up to two years of treatment with etanercept. Arthritis & Rheumatisim : New Allele Frequency Database: Middleton, D., Menchaca, L., Rood, H., Komerofsky, R. Tissue Antigens 2003, 61,

Spondylarthropathies. Outline. Introduction. Spondylarthropathy other than AS. Mimickers of spondylarthropathy. Conclusions.

Spondylarthropathies. Outline. Introduction. Spondylarthropathy other than AS. Mimickers of spondylarthropathy. Conclusions. Spondylarthropathies Filip M. Vanhoenacker Johan Van Goethem General Hospital St-Maarten Duffel-Mechelen Universities of Antwerp and Ghent Outline Introduction Spondylarthropathy other than AS Mimickers